Provider Demographics
NPI:1629109665
Name:JACKSON, MARY Y (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:Y
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 BURGESS LN
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27707-2933
Mailing Address - Country:US
Mailing Address - Phone:919-493-3888
Mailing Address - Fax:
Practice Address - Street 1:1804 MARTIN LUTHER KING JR. PARKWAY
Practice Address - Street 2:SUITE 210
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27707-2933
Practice Address - Country:US
Practice Address - Phone:919-489-2254
Practice Address - Fax:919-403-1551
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC001005101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6106541Medicaid